Posterior Proliferative Vitreoretinopathy Research Articles

Aerosolized, Gas-Phase, Intravitreal Methotrexate Reduces Proliferative Vitreoretinopathy in a Randomized Trial in a Porcine Model.

To determine the effectiveness of aerosol-delivered methotrexate (AD-MTx) in a large-animal (porcine) model of proliferative vitreoretinopathy (PVR). Prospective, randomized, interventional, double-masked, controlled, large-animal study with predetermined clinical and histopathologic outcome criteria. Half of the pigs were randomly assigned to receive an identical volume of aerosol-delivered normal saline (AD-NS) using identical delivery systems and treatment intervals. Proliferative vitreoretinopathy was surgically induced in 16 pigs (8 males and 8 females), randomly assigned to receive 2 doses (group A) or 3 doses (group B) of either AD-MTx (1.6 mg/0.4 ml) or normal saline (AD-NS). Group A pigs were euthanized at week 2 (n= 8), and group B pigs were euthanized at week 3 (n= 8). Masked clinical PVR scores (0-6) by a vitreoretinal surgeon and histopathology PVR scores (0-8) by a masked ophthalmic pathologist were used to determine outcomes. The mean, combined clinical and histopathology scores (both anterior and posterior) were used to determine the overall treatment effect between the groups. The mean masked score (± standard deviation) when all grading end points (clinical+ histopathology) were combined was a mean of 8.0 ± 2.3 in the AD-MTx group versus a higher 9.9 ± 2.0 in the AD-NS control group (P= 0.05). The clinical score was 3.88 ± 1.2 in the AD-MTx group versus 4.63 ± 1.6 in the AD-NS group (P= 0.16). The histopathology score for anterior PVR was 2.5 ± 0.8 in the AD-MTx group versus 2.5 ± 0.5 in the AD-NS group (P= 0.50), and the posterior PVR was 1.63 ± 1.6 in the AD-MTx group versus 2.75 ± 1.3 in the AD-NS group (P= 0.07). When the frequency of methotrexate dosing in group A (2 doses) was compared with that in group B (3 doses), the mean score was 8.75 versus 9.13 (P= 0.38), respectively, suggesting an insignificant difference. After surgical induction of PVR in an aggressive, high-risk, large-animal model, AD-MTx reduced posterior PVR formation compared with AD-NS. Additional dosing at week 3 did not improve the outcomes. No difference in anterior PVR formation was noted with intervention. This novel drug delivery system has implications for PVR reduction and warrants further investigation. Proprietary or commercial disclosure may be found after the references.

Proliferative Vitreoretinopathy Following Transscleral Diode Cyclophotocoagulation.

Transscleral diode laser cyclophotocoagulation may trigger the development of proliferative vitreoretinopathy. Our article demonstrates one such case leading to tractional macula off retinal detachment in a child with aphakic glaucoma. The purpose of this article is to describe a case of proliferative vitreoretinopathy (PVR) developing subsequent to transscleral diode laser cyclophotocoagulation (cyclodiode) in a pediatric patient with aphakic glaucoma. PVR most commonly occurs following rhegmatogenous retinal detachment (RRD) repair however, to the best of our knowledge, has never been reported to appear after cyclodiode. Retrospective evaluation of case presentation and intraoperative findings. A 13-year-old girl with aphakic glaucoma presented four months after cyclodiode of the right eye with a retrolental fibrovascular membrane and anterior PVR. The PVR extended posteriorly over the next month after which the patient developed a tractional macula off retinal detachment. Pars Plana vitrectomy was performed confirming dense anterior and posterior PVR. Review of the literature suggests an inflammatory cascade, similar to that seen in PVR development following RRD, may occur from the destruction of the ciliary body by cyclodiode. As a result, fibrous transformation may occur, likely accounting for the cause of PVR development in this case. The pathophysiology of PVR development remains unclear. This case demonstrates that PVR may occur following cyclodiode and should be considered during post-operative monitoring after this procedure.

Vitreoschisis and retinal detachment: New insight in proliferative vitreoretinopathy.

To assess the occurrence of peripheral vitreoschisis-induced vitreous cortex remnants (p-VCRs) in primary rhegmatogenous retinal detachment (RD) and investigate whether the presence of p-VCRs results in a greater risk of RD recurrence, secondary to Proliferative Vitreoretinopathy (PVR) development after pars plana vitrectomy (PPV). Patients who underwent PPV for primary rhegmatogenous RD between January 2016 and December 2018 were included. The presence of residual p-VCRs was confirmed intraoperatively using triamcinolone acetonide (TA). Patients with p-VCRs were divided into two groups: Group A comprised of patients who underwent PPV without p-VCR removal, while Group B included patients who underwent PPV with p-VCR removal. Four hundred-thirteen eyes with evidence of p-VCR were analyzed. Two-hundred-twenty-three eyes underwent PPV without VCR removal (Group A), while 190 eyes underwent PPV with p-VCR removal (Group B). Primary anatomical success was 91.5% in the Group A and 95.4% in the group B. Retinal re-detachment due to PVR occurred in 17 (7.6%) eyes in Group A and in four (2.1%) eyes in Group B within the first 3 months (p = 0.01). Among group A, in 11 eyes, there was a diffuse posterior PVR grade C, while six eyes were focal PVR grade C. In Group B, we observed four retinal re-detachment due to focal PVR grade C. The presence of p-VCRs seems to be associated with a higher incidence of PVR development and might also result in more complex RD recurrence, this suggests the need for more aggressive VCRs removal during the first surgery.

Objective Quantification of Retinal Shortening: Sonographic Evidence of Intraretinal Proliferative Vitreoretinopathy.

To evaluate retinal shortening with ultrasound (USG) in patients with retinal detachment (RD). This was a pilot, prospective, investigative study. Ten consecutive patients undergoing surgery for total RD with anterior or posterior proliferative vitreoretinopathy (PVR) graded more than grade C1 were included. Longitudinal USG B-scan was done for all patients to calculate retinal-to-choroidal length ratio (RCR). Quadrant-based RCRs and mean RCRs were calculated. All patients were followed for a minimum period of 3 months for unexplained recurrent retinal detachment. Mean duration of RD was 14.2 months and a mean of 2.8 retinal quadrants had epiretinal PVR, subretinal PVR, or both. Mean RCR was 0.81 and was the least in superior temporal quadrant. Seven patients developed recurrent RD, five at the first weekly visit. All of these patients had an RCR of less than 0.8 in at least one quadrant, whereas none of the remaining three patients had a quadrantic RCR of less than 0.8 (P = .008). Mean RCR was less than 0.8 in four of seven patients with recurrent RD (P = .2) CONCLUSION: Retinal shortening can be measured objectively with USG based RCRs. Low RCR in any retinal quadrant is a serious concern deserving appropriate patient counseling. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:746-750.].

Timing and outcomes after silicone oil removal in proliferative vitreoretinopathy: a retrospective clinical series.

ObjectiveTo evaluate anatomical and functional outcomes after silicone oil extraction in patients with retinal detachment and proliferative vitreoretinopathy in an eye care referral center in Joinville, SC, southern Brazil.MethodsRetrospective, noncomparative study of patients with retinal detachment and posterior proliferative vitreoretinopathy followed up after silicone oil removal. Prophylactic 360-degree peripheral laser photocoagulation was performed one to three months before silicone oil extraction. Patients with cataract underwent a combined clear corneal phacoemulsification with intraocular lens implantation in the same procedure. Anatomical outcomes were related to the duration of silicone oil tamponade and the surgical procedure performed. Functional outcomes were divided into three categories (stability, worsening, or improvement) according to visual acuity variation before the surgery and at the last follow-up visit.ResultsFifty-three patients were followed up for a mean period of 1,262 days.Fourteen eyes (26.4%) underwent cataract surgery combined with silicone oil extraction. Forty-eight eyes (90.5%) had attached retina at the last follow-up examination. Time of intraocular tamponade and association of phacoemulsification with silicone oil extraction were not considered as risk factors for retinal redetachment. Twenty-three cases (43.4%) showed visual acuity improvement, whereas 11 cases (20.8%) were stable and 19 cases (35.8%) showed visual acuity worsening. Five patients with attached retina had unexplained optic disc atrophy.ConclusionMost patients had good anatomical and visual outcomes after silicone oil extraction. Prophylactic 360-degree laser retinopexy may have led to favorable outcomes. Benefits of silicone oil extraction and the associated risks of complications due to a new surgical procedure must be carefully evaluated before surgical indication.

Intrasilicone oil injection of bevacizumab at the end of retinal reattachment surgery for severe proliferative vitreoretinopathy

To evaluate the role of bevacizumab injected into the silicone oil at the end of retinal reattachment surgery for rhegmatogenous retinal detachment (RRD) associated with severe proliferative vitreoretinopathy (PVR) for prevention of postoperative PVR and compare the results with those without intrasilicone injection. In this prospective comparative interventional study, eyes with RRD with grade C PVR were included. Standard 20 gauge pars plana vitrectomy, and retinal reattachment was performed. In case group, 1.25 mg bevacizumab was injected into the silicone oil at the end of surgery. The rate of retinal redetachment associated with PVR was assessed. In all 38 eyes of 38 patients (19 cases and 19 controls) with a mean age of 46.6 ± 18.3 years were studied. The two groups were matched for age, sex, preoperative visual acuity, presence of anterior and posterior PVR, extent of PVR, and history of previous retinal detachment surgery. Retinal redetachment with PVR occurred in nine (47.3%) and seven (36.8%) eyes in case and control groups, respectively (P=0.5). Extensive subretinal fibrous proliferations in addition to preretinal membranes occurred more in the case group (55.5 vs 14.3%). At final visit, visual acuity was similar between the two groups (1.6 ± 0.8 and 1.6 ± 0.6, respectively, P=0.9). Intrasilicone injection of bevacizumab at the end of vitrectomy for RRD with severe PVR does not eliminate the risk of postoperative PVR.

Retinotomy with retinal turnover to remove subretinal membranes under direct visualization for proliferative vitreoretinopathy

PurposeThe purpose of the study was to report the outcomes for cases of proliferative vitreoretinopathy (PVR) that received retinotomy and removal of subretinal proliferative tissue under direct visualization using retinal turnover.MethodsNineteen eyes with posterior and/or anterior grade C1–12 PVR that had undergone retinotomy and retinal turnover were reviewed. Main outcomes included the retinal reattachment rate, final best-corrected visual acuity (BCVA), postoperative intraocular pressure, extent of retinotomy, and complications.ResultsFinal retinal reattachment rates with silicone oil tamponade were 100%. The mean logarithm of the minimal angle of resolution (logMAR) BCVA was significantly improved (P = 0.001). Positive correlation was found between the extent of retinotomy and both preoperative logMAR BCVA (r = 0.663, P = 0.002) and postoperative logMAR BCVA (r = 0.619, P = 0.005). There was no correlation between the extent of retinotomy and the change in preoperative and postoperative logMAR BCVA (r = −0.267, P = 0.268). Negative correlation was found between preoperative logMAR BCVA and the change in logMAR BCVA (r = −0.587, P = 0.008). There was no correlation between the extent of retinotomy and the intraocular pressure at the final visit (r = −0.316, P = 0.188). Corneal decompensation due to silicone oil in the anterior chamber occurred in one eye.ConclusionRemoval of subretinal proliferative tissue with retinal turnover seems to be an effective procedure.

RISK FACTORS FOR THE DEVELOPMENT OF TRANSIENT HYPOTONY AFTER SILICONE OIL REMOVAL

The purpose of the study was to determine the incidence, duration, and risk factors for postoperative transient hypotony after pars plana silicone oil removal. This was a retrospective, noncomparative, interventional case series. The records of 89 eyes of 89 patients who underwent pars plana silicone oil removal with at least 6 months of follow-up were reviewed. Postoperative transient hypotony was defined as an intraocular pressure of <6 mmHg occurring within 1 week of surgery, which recovered within 4 months after surgery. Transient hypotony occurred in 35 of 89 eyes (39.3%). Thirty-three eyes recovered within 1 week after surgery. The logistic regression model, including age, number of previous pars plana vitrectomies, number of intraoperative endolaser applications, extent of remaining posterior proliferative vitreoretinopathy and the degree of proliferative vitreoretinopathy removal, number of preoperative antiglaucoma ophthalmic solutions, duration of postoperative anterior chamber inflammation, axial length, preoperative intraocular pressure, and duration of oil tamponade, showed that only axial length was significantly associated with the development of postoperative transient hypotony (odds ratio = 1.385, P = 0.023). Transient hypotony frequently developed after silicone oil removal, and most cases recovered within 1 week postoperatively. Patients with a long axial length had increased odds of developing transient hypotony after silicone oil removal.

Efficacy and safety of heavy silicone oil Densiron 68® in the treatment of complicated retinal detachment with large inferior retinectomy

To assess the efficacy and safety of a heavy silicone oil (Densiron 68 a mixture of perfluorohexyloctane (F(6)H(8)) with silicone oil as temporary internal tamponade in selected retinal detachments treated with large inferior retinectomy. Complicated retinal detachments with severe posterior and anterior proliferative vitreoretinopathy (PVR) were included in this study. In all cases, a large inferior retinectomy involving the inferior quadrants was performed. Densiron 68 was injected at the end of surgery after perfluorocarbon injection. A minimum follow-up of 6 months was required in order to be included in this retrospective study. Twenty-seven patients were operated on with a mean follow-up of 57.5 weeks. Twenty-three patients presented a posterior PVR > CP6 and 26 patients an anterior PVR > CA5. Heavy silicone oil was removed in 19 patients after a mean follow-up of 14 weeks. At the 4-week follow-up visit, only one retinectomy was reopened by a recurrent inferior retinal detachment with PVR CP3. Finally, anatomical success was achieved in 25 of the 27 patients (92.5%) after Densiron 68 removal at the last follow-up. The main adverse effect was inflammatory reaction with fibrin accumulation in the anterior chamber (40.7%). Densiron 68 appeared to be an efficient endotamponade agent in selected retinal detachments treated with large inferior retinectomy. It avoids fluid accumulation under the inferior retina and seems to limit the rate of inferior retinectomy reopening.

Recurrent retinal detachment more than 1 year after reattachment

Purpose Little information exists regarding recurrent retinal detachment after 1 or more years of complete retinal reattachment. To better understand this uncommon problem, we evaluated late recurrent retinal detachments in relation to the contemporary classification of proliferative vitreoretinopathy (PVR). Design Retrospective consecutive noncomparative case series. Participants Nine patients (10 eyes) with late recurrent retinal detachment after 1 or more years of complete reattachment. Methods We retrospectively analyzed the clinical and operative records of one surgeon over a 9-year period to identify late recurrent retinal detachments that occurred 1 or more years after complete retinal reattachment. The study group was derived from a total of 453 consecutive cases of rhegmatogenous retinal detachment repair not associated with proliferative diabetic retinopathy, uveitis, or penetrating ocular trauma. Main outcome measures Late recurrent retinal detachments after 1 or more years of complete retinal reattachment. Results The study group consisted of 10 eyes (2.2% of total) in nine patients. Redetachment occurred from 12 to 126 months (average, 46.8 months) after the initial detachment surgery. Late recurrent retinal detachments were associated with new retinal breaks (five eyes), reopening of old breaks (three eyes), or both (two eyes). In all, 13 open breaks were identified, nine of which were on or anterior to the scleral buckle. Eight eyes had grade C PVR, including four eyes with anterior PVR, three eyes with posterior PVR, and one eye with both anterior and posterior PVR. The retina was reattached after additional vitreoretinal surgery in eight eyes of seven patients; two patients (two eyes) declined reoperation. Visual acuity improved in seven of eight eyes after repair of the late recurrent retinal detachment. Postoperative follow-up after late recurrent detachment repair ranged from 69 to 140 months (average, 101.7 months, or 8.5 years). Conclusions Vitreous base traction seems to be an important factor in late recurrent retinal detachments occurring 1 or more years after complete retinal reattachment, and the associated PVR was probably a secondary phenomenon and not a causative factor in most cases. Reoperation for such late recurrent retinal detachments can successfully reattach the retina and improve visual acuity in most cases.

Recurrences of Retinal Detachment after Vitreoretinal Surgery, and Surgical Approach

To investigate the causes and management of recurrences of complicated retinal detachment after vitreoretinal surgery. Vitreoretinal surgery was performed in 61 patients with complicated retinal detachment who were followed up for 4-24 (mean 7) months. Liquid perfluorocarbon (PFC) was used in all 61, silicone oil in 40 and perfluoropropane (C3F8) in 18 patients. Retinal attachment was achieved in 58 patients (95%) during the first operation. Due to the recurrence of detachment 17 patients (29%) had to be operated for a second, 7 (12%) a third and 4 (7%) a fourth time. Anterior and posterior proliferative vitreoretinopathy, missed tear, retinal incarceration, subretinal membrane and perisilicone proliferation were the factors causing redetachment. The best anatomical and functional results are obtained by dissection of the anterior membranes. In order to properly remove the retinal periphery the crystalline or intraocular lens should be removed. Comparison of our results with others indicates that anatomical success depends, to a certain extent, on doing only one, radical operation on the pathology that leads to recurrence.

Porcine model of proliferative vitreoretinopathy with platelets

PURPOSE. To develop an experimental model of proliferative vitreoretinopathy (PVR) in the pig, and determine the efficacy of platelet-derived growth factor (PDGF) compared with different platelet plasma concentrates in its development. METHODS. Animals were divided into four groups of 12 pigs each. Groups 1, 2, and 3 underwent four 3-mm-long retinotomies, a partial mechanical vitrectomy, and six transconjunctival retinal cryoapplications and were injected intravitreally with, respectively, 0.2 ml of platelet rich plasma, 0.2 ml of a solution containing 200 ng of porcine PDGF, and 0.2 ml of platelet concentrated plasma. Group 4 received only an intra-vitreal injection of 0.2 ml of porcine PDGF. RESULTS. In Group 1, retinal detachments (RDs) developed in six eyes (50%) (two eyes, total RDs; four, extensive RDs). In Group 2, focal RDs developed in six eyes (50%). In Group 3, 11 eyes (92%) developed Rds (six eyes, total RDs; three, extensive RDs, two, focal RDs). Group 4, did not develop lesions. Statistically significant differences were found between Group 3 and the other groups. Group 2 RDs were associated with the presence of vitreoretinal membranes but there were no signs of PVR. In Groups 1 and 3, signs of anterior PVR, posterior PVR, and retinal holes with rolled edges were observed. CONCLUSIONS. We have developed a model of PVR in the pig, the retina of which more closely resembles that of humans. Platelet plasma more effectively contributed to the development of an experimental model of porcine PVR than 200 ng of PDGF. The efficacy depends on the platelet concentration of the plasma. These results suggest that other growth factors and plasma components may interact synergistically with PDGF in the pathogenesis of PVR.

Anterior Proliferative Vitreoretinopathy in the Silicone Study: Silicone Study Report Number 10

As part of the design of the Silicone Study, a new classification of proliferative vitreoretinopathy (PVR) was developed that distinguishes the different types of contraction found in PVR. In contrast to the original Retina Society system that emphasized the post-equatorial retinal pathology (posterior PVR), the Silicone Study classification system included the characteristic types of contraction found in both the equatorial region and the pre-equatorial retina and vitreous base (anterior PVR). The authors contrast (1) preoperative and intraoperative findings and (2) vision and anatomic outcomes in the cohort of anterior PVR eyes with the cohort of posterior-only PVR eyes. For the cohort of eyes randomized to perfluoropropane gas (C3F8) or silicone oil, the authors carry out univariate and multivariate analyses to assess the predictive value of baseline and intraoperative parameters on vision and anatomic outcome. Anterior PVR was present in 321 eyes (79%) and was more prevalent in eyes that had undergone an unsuccessful vitrectomy before study entry than in eyes that underwent a primary vitrectomy for PVR (88% versus 73%; P < 0.001). Compared with eyes that had posterior PVR at the preoperative examination, eyes that had anterior PVR tended to (1) be graded (Retina Society classification system) as D-1 or worse (86% versus 49%; P < 0.0001), (2) have worse (< 2/200) visual acuity (93% versus 86%; P = 0.003), (3) have more hypotony (24% versus 11%; P = 0.03), more edema (8% versus 2%; P = 0.04), more aqueous flare (P = 0.02), more macular pucker (69% versus 52%; P = 0.005), and more intravitreal contraction (21% versus 6%; P = 0.002). When compared with eyes that had anterior PVR, eyes with posterior PVR had a better outcome at the 6-month postoperative examination: complete attachment of the retina (76% versus 62%; P = 0.04), visual acuity of 5/200 or better (64% versus 45%; P = 0.006), and normal intraocular pressure (86% versus 71%; P = 0.04). For eyes with anterior PVR, significant predictors of poor (< 5/200) visual acuity were a preoperative PVR grade D-1 or worse and the use of C3F8 gas as the intraocular tamponade. The Silicone Study classification of anterior PVR permits greater specificity in characterizing PVR and is prognostic of anatomic and vision outcome. Eyes with anterior PVR and clinically significant posterior PVR changes had a better visual prognosis if silicone oil was used. With the current understanding of the pathoanatomy of anterior PVR and the recent development of new surgical techniques, the incidence of anterior PVR in eyes that previously underwent vitrectomy may decline, and the prognosis in eyes with anterior PVR may improve.

Silicone Oil Tamponade for Retinal Detachment and Delayed Treatment of Retinal Tears

Four patients underwent a vitrectomy procedure for retinal detachment associated with anterior and posterior proliferative vitreoretinopathy (D-1 type). In each patient, an internal tamponade was achieved with 1000-centistoke silicone oil. Preretinal and/or subretinal hemorrhage that was difficult to remove during surgery, as well as remnants of subretinal fluid, prevented complete intraoperative treatment of the retinal tears or the retinotomy with endolaser photocoagulation. The silicone oil tamponade kept the retina flat until laser treatment was applied to the retinal tears several weeks later, when the retinal blood and subretinal fluid had reabsorbed. When circumstances make achieving intraoperative laser marks difficult, silicone oil tamponade appears to be superior to a long-lasting gas tamponade. It provides a more permanent tamponade than gas and excellent visualization of the fundus several weeks after surgery, at which time laser marks can be completed.

Management of Giant Retinal Tears without Scleral Buckling: Use of Radical Dissection of the Vitreous Base and Perfluoro-octane and Intraocular Tamponade

The introduction of intraoperative perfluorocarbon liquids in the management of giant retinal tears has allowed exact anatomic reapposition of the retina and the giant retinal tear. Therefore, the authors managed 11 eyes with giant retinal tears and no proliferative vitreoretinopathy without scleral buckling. Maximum removal of the basal vitreous gel was performed in all cases, and perfluoro-octane was used intraoperatively to unfold the inverted posterior flap and reattach the retina completely. Endophotocoagulation was applied to the edges of the tear and perfluoropropane or silicone oil was used as an intraocular tamponade. Although 1 eye required reoperation for a redetachment from posterior proliferative vitreoretinopathy, all retinas were reattached with final visual acuity of 5/200 or better in 9 eyes. Eight additional major procedures were necessary in seven eyes: removal of silicone oil in four (with removal of perisilicone proliferation in three), repeat vitrectomy and membrane removal with photocoagulation twice in one eye, cataract extraction in one eye, and removal of a macular pucker in one eye. Four eyes required postoperative fluid-gas exchange and three eyes had tissue plasminogen activator injections into the anterior chamber for postoperative fibrin reactions.

Causes of Failure After Repeat Vitreoretinal Surgery for Recurrent Proliferative Vitreoretinopathy

During the last two years, we performed vitreoretinal surgery on 37 eyes with retinal detachments and recurrent severe proliferative vitreoretinopathy in 37 patients who had had previous failed scleral buckling and vitreous surgery for proliferative vitreoretinopathy. Anterior proliferative vitreoretinopathy was present in 32 of 37 eyes (86%); posterior proliferative vitreoretinopathy of fixed retinal folds in four quadrants of narrow or closed funnel shape occurred in 23 of 37 eyes (62%); and subretinal proliferation was noted in 16 of 37 eyes (43%). The retinas in 12 eyes (32%) redetached from new or recurrent anterior proliferative vitreoretinopathy in nine eyes, reopening of pre-existing retinal breaks in two eyes, or recurrent posterior periretinal proliferation in one eye. With additional vitreoretinal procedures in six eyes and after a mean follow-up period of 11 months, 27 of 37 retinas (73%) were totally reattached, and an additional five eyes (13%) had retinal reattachment posterior to the scleral buckle. Of the 32 patients with posterior retinal reattachment, final visual acuity of 5/200 or better was attained in 19 eyes (59%).

Klinische Diagnostik der proliferativen Vitreoretinopathie

The clinical features of a proliferative vitreoretinopathy (PVR) are systematically described. The patient's history reveals moderate lost of vision and metamorphopsia. Ophthalmoscopy, biomicroscopy of the fundus with the contact lens, and black-and-white photography usually lead to the correct diagnosis. Early stages of PVR are characterized by increased reflectance and a cellophane appearance of the inner retinal surface and tortuosity of both small and larger vessels. Advanced epiretinal tissue formation causes development of surface wrinkling and single or multifocal star-folds. In cases of retinal detachment with PVR, the retina is immobile, the detachment being concave due to traction or bullous if there are secondary breaks. In the final stages of posterior and/or anterior PVR the detached retina forms a narrow or closed funnel.